IUD Insertion Clinic Checklist
**Must be completed by referring MD**
Fax # for referral 470-7061
Please note that this is an insertion clinic only and all listed requirements must be
completed prior to patient’s appointment. Please inform your patient that this is a
teaching clinic and learners will be present for the entire appointment.
Patient information:
Name: ___________________________
DOB:
G____ P____ A ___
Vaginal Delivery x _____ ; C/S x ______

Patient has been counselled regarding insertion, safety of Mirena or Nova T, and
all risks involved. Insertion procedure and management will be reviewed the day of
the appointment.

Patient has a Rx for the IUD and is advised to bring it with her to clinic apt. There
are no further compassionate IUDs available though the IWK clinic.

Chlamydia and gonorrhea swabs completed and results attached.

Pap smear completed. Pap smears will not be performed, as results cannot be
followed in clinic.

If reason for IUD insertion is menorrhagia, appropriate work up is to be completed
and attached (blood work, ultrasound, endometrial biopsy). Should results not be
attached insertion will not occur. Work up and management post insertion is to be
completed by referring physician.

Patients who are nulliparous or have only had caesarean sections require a
prescription for Misoprostol 200 mcg with instructions to insert vaginally the
morning of the appointment. Patients who have had previous spontaneous vaginal
deliveries do not require misoprostol.
o Misoprostol given Yes ______

No ______
It is recommended that patients have a drive home as many patients have a vasovagal
response and are unable to drive safely.
Updated Feb 2013